Introduction to the assessment and management of upper limb injuries.

1. Upper Limb Injuries

2. Objectives
 To understand the key elements of the
history and examination technique.
 To review the management of common
children’s injuries.
 To highlight some pitfalls.

3. Background Information
 Parents often seek medical help
because their child has a limp arm.
They are reluctant to use the arm and
passive movements are resisted.
 More than one injury in the limb may be
present.
 Small children readily sustain minor
fractures.

4. History
 Is there a history of trauma?
 Is their a current or previous health
condition associated with any pre-
disposition to bone, joint or other
musculoskeletal problems?
 When and How did the problem come
to light?

5. Examination: General Principles
 Is the child febrile?
 Ensure the upper half of the child is
completely undressed.
 Compare painful limb with normal one.
 Examine anterior and posterior
surfaces.
 Don’t forget to assess C-Spine.

6. Look
 ? Torticollis
 Erythema
 Wounds
 Swelling
 Bruising
 Deformity
 Wasting
 Scarring
 Symmetry

7. Feel
 Palpate the whole limb from sterno-
clavicular joint.
 Heat?
 Tenderness
 Crepitus
 Circulation
 Sensation

8. Move
 Check joints of uninjured limb first.
 Make it a game e.g. ‘Simon Says’
 Assess active ‘v’ passive
 Note range of movement of each joint.

9. Investigations
 Temperature and Pulse are mandatory.
 Bloods for FBC, CRP, ESR, Culture if
infection or inflammation are suspected.
 X-rays: Locate tenderness and only X-
Ray specific joints or bones. (Do NOT
do and armogram.)

10. Differential Diagnoses
 Fracture
 Septic Arthritis, Osteomyelitis or Bone
Pathology.
 Osteochondritis (e.g. Capilulum or Lunate)
 Soft Tissue Injury
 Pulled Elbow
 Penetrating Foreign Body
 Arthropathy (e.g. Viral, Henoch-Schonlein
Purpura, Sickle-Cell Crisis etc)
 Pain referred from neck or neurological cause

11. Fracture
 Fracture of the Clavicle is a frequently missed
diagnosis in small children. Reasons fro this
are:
 The child is not properly undressed and attention
is focussed on the upper arm, elbow or forearm.
 Swelling or bruising over the clavicle may be
subtle.
 X-Ray of the upper limb may not include the
medial half of the clavicle.

12. Fracture
 The Supracondylar fracture of the
humerus is one of the commonest
fractures in children (Usually aged 4-10)
 Swelling is usually obvious at the elbow.
 Careful attention should be given to
neurovascular status of the limb.

13. Fracture
 Forearm fractures may be subtle.
 X-Rays should demonstrate the whole
of the raduis and ulna to ensure
recognition of either Montegia or
Galleazzi fractures.

14. Septic Arthritis
 All movements are exquisitely painful.
 Blood Tests and Aspiration are usually
confirmatory.
 X-rays are usually normal for up to 10 days.
 Distinguish septic arthritis from less inflamed
arthropathies which may affect more than
one joint.
 The child is usually systemically unwell.

15. Osteochondritis
 Usually affects capitulum of distal
humerus or the lunate (Kienblock’s
Disease).
 Diagnosed from local tenderness and
increased bone density or
fragmentation on X-Rays.
 The child is systemically well.

16. Pulled Elbow
 Commonest clinical diagnosis based on
loss of elbow function after a traction
injury. (Typically aged 2-5 yrs)
 There is no significant elbow swelling or
inflammation.
 The arm is usually held in extension.
 X-rays reveal no abnormality.

17. Do NOT manipulate a pulled
elbow without X-ray unless
there is a clear history of
witnessed traction injury.
People have been sued for
manipulating supracondylar fractures.

18. Management: Fractures
 Ensure Adequate Analgesia
 Clavicular Fractures
 Broad Arm Sling
 Humeral Head, Shaft and Supracondylar
Fractures
 Refer Orthopaedics
 Dislocations
 Refer Orthopaedics
 Undisplaced forearm fractures
 Above Elbow Backslab, R/V #Clinic
 Undisplaced wrist fractures
 Below Elbow Backslab, R/V #Clinic

19. Management: Septic Arthritis
 Take blood for Culture and commence
broad spectrum I.V. antibiotics.
 Joint will need aspiration =/- Irrigation
in theatre.

20. Management: Osteochondritis
 Rest and analgesia
 Refer Orthopaedic Outpatients.

21. Management: Pulled Elbow
 Gain informed consent from parents.
 Give analgesia
 Attempt manipulation
 Most children will only let you do this once
 Observe at play
 If unsuccessful-X-Ray
 Review in one day if no improvement.

22. Summary
 Upper limb problems are common in
children.
 Use a sytematic approach to
examination.
 Have a low threshold for X-Ray.